Archives for Health

Transporting vital supplies and critical commodities quickly to the epicenter of an international disaster is what USAID’s Office of U.S. Foreign Disaster Assistance does every day. However, the Ebola response has proved especially challenging for USAID’s disaster experts.

“Most disasters we respond to are either natural disasters—such as an earthquake, where the acute needs peak and then go down very quickly—or it’s a war,” explained Kelly Bradley, a logistician with USAID’s Ebola Disaster Assistance Response Team (DART). “Ebola is essentially a brand-new type of response because outside of a few groups, no one has dealt with it on a large scale before.”

Inside the cargo hold, thousands of sets of protective equipment (PPE) to protect Ebola health care workers. As of January 2015, the U.S. has transported more than 400 metric tons of medical and disaster supplies to West Africa. / Carol Han, USAID/OFDA

One major obstacle: Affected West African countries did not have robust infrastructure in place to receive and distribute all the goods pouring into their airports. As a result, the United States found itself in the unique position of moving an unprecedented amount of medical supplies to a region while simultaneously working to build a logistics supply chain almost from scratch—all to ensure that health care workers are able to get what they need to save lives.

USAID Ebola Disaster Assistance Response Team (DART) logisticians Kelly Bradley and Rogers Warren receive medical supplies at Roberts International Airport in Monrovia, Liberia. In addition to airlifting critical commodities, they had to help build a supply chain to ensure that the medical supplies got to areas of need. / Carol Han, USAID/OFDA

“We were getting requests left, right and center,” said Bradley. “People didn’t know what they were asking for. We didn’t know what was coming in a lot of the time. Even the experts who do medical responses didn’t fully understand the scope of the need.”

Inside a warehouse in Monrovia, the U.S. military and USAID put together “starter kits” of medical and cleaning supplies to sustain U.S.-supported Ebola clinics for the first critical days of operation. / Carol Han, USAID/OFDA

Much of the need centered on delivering enough personal protective equipment (PPE) – including gloves, goggles, coveralls, masks and boots—to health care workers. Enter the U.S. military, which has been working closely with USAID to airlift more than 1.4 million sets of PPE to Monrovia, the country’s capital.

However, once the supplies were flown in, there was no dedicated system in place to transport them to the Ebola treatment units (ETUs) being constructed and staffed by the United States.

USAID funded the UN World Food Program (WFP) to build a system of warehouses in five strategic locations throughout Liberia. Photo courtesy: Carol Han, USAID/OFDA

That’s when USAID partnered closely with the UN World Food Program (WFP) and supported its work to build a system of warehouses throughout the country and develop a supply chain of medical equipment to ensure ETUs received ample resources to open its doors and stay operational.

With this supply chain in place, PPE and other medical supplies could now be transported by truck to logistics bases located in five strategic Liberian cities, close to U.S.-supported ETUs.

In addition to supplying Ebola Treatment Units with medical equipment, USAID has been providing communities with household kits containing bleach, masks, soap and gloves so that families taking care of sick loved ones could be better protected against Ebola. / Carol Han, USAID/OFDA

Mira Baddour, a logistician with WFP in Liberia, admits that getting all the main players on the same page was initially very challenging.

“For us, for WFP, we usually deal with delivering food,” Baddour explained. “Now, we were dealing with unfamiliar concepts like ETUs and working with different partners. But [being here] is really a great experience for me… and everyone is now working very well with each other.”

“It’s a totally different crisis,” said WFP logistician Mira Baddour at one of the warehouses in Liberia that her agency is running. “It has been challenging, but at the same time it is a really great experience for me.” / Carol Han, USAID/OFDA

USAID’s Kelly Bradley, who is a veteran of several disasters, agrees that the experience has been personally rewarding.

“Think about the sheer volume of personal protective equipment that [has been] coming in,” said Bradley. “My unit is directly responsible for making sure that it gets to our partners… the Ebola health care workers on the frontlines. It’s a really big responsibility and a really rewarding thing to be a part of it all.”

Meet the team of experts with USAID, the U.S. military, and the UN World Food Program that have been working around the clock to transport, track and deliver critical medical supplies for the Ebola response. / Carol Han, USAID/OFDA

ABOUT THE AUTHOR

The Ebola Disaster Assistance Response Team (DART) is overseeing the U.S. Ebola response efforts in West Africa. The DART includes staff from across the U.S. Government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

To learn how to safely treat Ebola patients while staying alive, doctors and nurses must learn how to navigate an Ebola “maze” run by the U.S. military in Liberia. / Carol Han, USAID

Walk into the gymnasium of the Liberian National Police Training Academy and you’ll come across a maze so bizarre—and as it turns out so high-stakes—that successfully navigating it could mean the difference between life and death.

Welcome to the nerve center of the U.S. health care worker training program. It’s a replica of an Ebola treatment unit (ETU), where doctors, nurses, hygienists, and others learn how to safely care for Ebola patients while staying alive.

The U.S.-run Ebola health care worker training takes place at the Liberian National Police Academy, where the gymnasium has been transformed into a mock Ebola treatment unit. / Carol Han, USAID

“Everything is about safety—the safety of the staff and the safety of the patients,” said U.S. Army Colonel Laura Favand, who helps oversee the Ebola health care worker training program.

During the week-long class, students first spend three days in the classroom where U.S. military doctors, nurses and medics teach them every aspect of Ebola care, from diagnosis and patient recordkeeping to proper disinfection techniques and safe handling of the dead.

Cross-contamination is the biggest threat in an ETU, which is why there’s an entire class dedicated to proper hand-washing techniques. Another critical lesson: how to take off protective suits, goggles, and gloves without inadvertently contracting the disease.

According to Colonel Favand, this is one of the most vulnerable times for Ebola health care workers.

Taking off protective suits—like what’s being done here at a USAID-supported ETU in Sierra Leone—is a vulnerable time for health care workers. That’s why so much time is spent teaching health care workers how to prevent cross-contamination. / Carol Han, USAID

“You’ll see someone getting ready to take their gloves off and their hands are shaking,” said Favand. “They know how important this is.”

Classroom time is followed by two days spent in the “mock ETU” where students are taught how to navigate in a clinical setting and practically apply all that they have learned. Actual Ebola survivors play the role of patients, offering invaluable insight into what actually happens in an ETU. According to participants, the survivors also help teach them how to communicate with patients.

Actual Ebola survivors play the role of patients at U.S. Ebola health care worker trainings, providing invaluable insight. Here, a student assesses a child patient and Ebola survivor during a training session in Greenville, Liberia under the watchful eyes of the instructor. / Col. Laura Favand, U.S. Army

“We learn some different terms in Liberian English that allows us to have a more accurate perception of the patient,” said Ephraim Palmero, medical director for the International Organization of Migration, an organization being supported by USAID to run three U.S.-built ETUs in Liberia.

On the Road: The U.S. military has deployed mobile training teams throughout Liberia to offer the same course to those who can’t travel to the main training site in the Monrovia metro area. / Carol Han, USAID

Besides running the training at the Liberian police academy, the U.S. military deploys four mobile training teams throughout Liberia to offer the same course to health care workers who are unable to make it to Monrovia. Liberian health officials — in charge of training the next generation of Ebola health care workers — also take the class.

“I love doing this mission,” said U.S. Army Captain Alex Ailer. “I like that people here are being helped and that we are also helping local people help themselves.”

U.S. Air Force Senior Airman Alexander Muniz and U.S. Army Captain Anna Bible take a break while teaching an Ebola health care training course in Harper, Liberia. They are part of a mobile training team. / Carol Han, USAID

As of early January 2015, more than 1,500 Liberian and international health care workers have taken part in the training, including several USAID partners that are now running the U.S.-built ETUs.

“The training was incredible and great for me because it alleviated my fears,” said Micaela Theisen with the International Organization for Migration. “It [made] me feel good and ready to get to work.”

Her colleague Catherine Thomas agreed.

“The staff there, their medical knowledge was very comforting to us who were just starting out.” said Thomas. “They were just great.”

From left to right: Health care workers Catherine Thomas, Micaela Theisen, and Rene Vega—all working at USAID-supported ETUs—have taken the U.S. Ebola health care worker training course. “The training was incredible and great for me because it alleviated my fears,” said Theisen. / Carol Han, USAID

The Ebola Disaster Assistance Response Team (DART) is overseeing the U.S. Ebola response efforts in West Africa. The DART includes staff from across the government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

ABOUT THE AUTHOR

Carol Han is a Press Officer for the Ebola Disaster Assistance Response Team (DART), which oversees the U.S. Ebola response efforts in West Africa. The DART includes staff from across the government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

A nurse in the perinatology unit at the Jaime Moto Regional Hospital in Barahona attends to a newborn after receiving training in preventing mother to child transmission of HIV. The training was conducted through CapacityPlus, a USAID-funded project to strengthen the health work force in the Dominican Republic. / Wendy Tactuk, courtesy of CapacityPlus and IntraHealth International

The recent focus on Ebola in West Africa has reminded us of the need for strong and resilient health systems. Behind every quality health system is an army of available and accessible health workers. However, in facilities and communities across the globe, health worker vacancies and weak support systems hamper achievement of health goals and threaten overall preparedness for future infectious diseases.

In most countries with a high HIV burden, health work force shortages are commonplace and create significant barriers to combating the epidemic.

Much has been accomplished. USAID is incredibly proud of its significant contributions to PEPFAR’s (the U.S. President’s Emergency Plan for AIDS Relief) achievements in strengthening the health work force to deliver quality HIV services. On World AIDS Day, Secretary Kerry announced that PEPFAR has exceeded the target of 140,000 new health care workers, which was mandated by Congress in 2008. This is a great milestone not only for PEPFAR, but also for the broader global health work force agenda.

A strong health work force composed of both facility- and community-based workers is essential for achieving an AIDS-free generation. Health workers are key to making sure that people living with HIV access the appropriate services at the right time, ensuring effective linkages across HIV services and clients’ continuum of care. Health workers also play a critical role in providing HIV services to vulnerable populations, including children, adolescents and other key populations.

USAID has an extensive history in training and educating health workers. For the last decade, the Agency has been at the forefront of advocating for a growing focus on the health work force in the global health agenda. USAID has also supported a breadth of innovative program models that have made immense contributions to the health worker target.

A physician and nurse examine a young patient at a clinic in Mbarara, Uganda, one of 11 main service centers and clinics managed by The AIDS Support Organization (TASO), a large local NGO receiving USAID funding to provide care and support for orphans and vulnerable children. / USAID, Tash McCarroll

For example, USAID and the Touch Foundation created a PEPFAR-supported public-private partnership in Tanzania to expand training of health workers and strengthen management capacities of the Catholic University of Health and Allied Sciences and Bugando Medical Center. Through this partnership, student enrollment has jumped from 277 students to over 1,800 across 14 different health worker cadres—a sixfold increase since 2004. Enrollment of medical students alone increased from 10 to 750 students over the last 10 years.

The program has also focused on strengthening deployment of graduates to underserved rural areas with the highest prevalence of infant and maternal mortality, HIV and malaria. With 96 percent of medical doctors trained in the program still employed in the Tanzanian health system, the program has become a model for achieving high graduate placement and retention rates.

However, there is still work to be done. Significant health work force shortages remain and systemic challenges continue to impact the support needed to enable and sustain health workers’ delivery of HIV services.

The new PEPFAR Human Resources for Health (HRH) strategy highlights the need to overcome these barriers. USAID continues to contribute to PEPFAR’s health work force investments by building upon and leveraging past contributions and advancements that span beyond training and include health worker deployment, retention and management.

The strategy’s five objectives outline a common roadmap for ensuring adequate supply and quality of the health work force to expand and sustain HIV and AIDS services:

Establish sustainable financing for health workers, which ensures adequate local financing for health workers that provide HIV/AIDS services and sustained capacity for sites where PEPFAR salary support has been transitioned.

Improve health worker performance for service quality.

We often, and rightly so, think about our impact from the perspective of the clients we serve. But it is also important to see through the lens of the health workers who have devoted their lives to serving others and have worked tirelessly in mediocre conditions. What is preventing them from doing their jobs effectively? What additional support do they need? That perspective may help us get one step closer to achieving an AIDS-free generation.

ABOUT THE AUTHOR

Diana Frymus is the Health Systems Strengthening Advisor in the Office of HIV/AIDS

Nurses apply chlorhexidine to the umbilical cord of a newborn at Nepalganj Medical College & Teaching Hospital. USAID is helping Nepal bring the life-saving antiseptic gel to villages, communities and health centers across the country. / Thomas Cristofoletti for USAID

In the maternity ward of a USAID-supported hospital in Dhulikhel, a town on the eastern rim of the Kathmandu Valley in Nepal, I watched a nurse apply a disinfectant gel to the umbilical cord of a newborn baby. That tube of the antiseptic chlorhexidine — worth under 15 cents — has been shown in a randomized control trial, to reduce neonatal mortality by a remarkable 34 percent in Nepal.

Thanks to simultaneous advances in health, education, nutrition and access to energy, Nepal stands at the edge of its prosperity. On the path to overcoming the remnants of internal conflict and transitioning to democracy, the Nepalese have cut extreme poverty by 50 percentage points in the last two decades.

Gita, a female community health worker, visits a pregnant woman and her family to show them how to use the chlorhexidine antiseptic gel and how to apply it to the umbilical cords of newborns. / Thomas Cristofoletti for USAID

Innovative programming like chlorhexidine application is growing more common in Nepal and around the world. USAID is also supporting creative community-based approaches to countering human trafficking, including a novel effort to criminalize organ sales that has won landmark court cases, setting new precedent in Nepalese law for holding traffickers accountable.

A focused effort to improve early-grade reading is supporting the Ministry of Education’s School Sector Reform Plan by strengthening curricula and training teachers, school committee members, parents and technical support staff in more than 27,000 Early Childhood Education Development centers across the country. Just a 10 percent increase in the share of students with basic literacy skills can boost a country’s economic growth by 0.3 percentage points, while laying the foundation for their later learning.

We need these kinds of disruptive innovations to help bend the curve toward increased child survival, better access to justice, lower malnutrition, greater literacy and skills, and, ultimately, the end of extreme poverty. Solutions like these will drive broader development progress and elevate our efforts to realize transformative change, and now, 2015, is the time to do it.

This year will be a pivotal year for international development. In Addis Ababa this summer, leaders will come together at the third Financing for Development conference to agree on a new compact for global partnership.

In the fall at the U.N. General Assembly in New York, heads of states will ratify a post-2015 development agenda, a universal, more comprehensive, more ambitious follow-on to the Millennium Development Goals, outlining a vision for the next 15 years of development progress. And in Paris next December, member states will adopt a new agreement to combat global warming at the 21st Conference of Parties to the U.N. Framework Convention on Climate Change.

A worker for Lomus Pharmaceutical packs tubes of a chlorhexidine antiseptic gel that is one of Nepal’s great innovations and success stories in global health. The gel, when applied to the cut umbilical cord stumps of newborns, instead of traditional substances like oil, curry powder or ash, can reduce the risk of infant death by up to a third. / Thomas Cristofoletti for USAID

While the solution to a vexing challenge like neonatal mortality may seem as simple as applying a bit of antiseptic ointment at the right time, this breakthrough came only after a dedicated and concerted effort to hammer away at the problem. USAID worked in partnership with academic researchers, government service providers, community extension workers, private-sector drug manufacturers and others to rigorously pilot, test and scale the Chlorhexidine project.

By focusing our efforts on disruptive innovations such as Nepal’s successful chlorhexidine project and using the U.S. Global Development Lab to design, test and scale similar interventions around the world, USAID will help bend the curve towards the end of extreme poverty.

ABOUT THE AUTHOR

Alex Thier is the Assistant to the Administrator in the Bureau for Policy, Planning and Learning. He tweets from @Thieristan

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This post originally appeared December 31, 2014 on the International Medical Corps website. It has been reposted here with permission.

Photo courtesy of International Medical Corps

Bong County, Liberia – Korto was admitted to International Medical Corps’ Ebola Treatment Unit (ETU) in late November, while her four-month old daughter Josephine, who tested negative for Ebola, was cared for nearby. Although deeply saddened by being separated from her young baby, Korto maintained such positivity during her treatment. The whole medical team couldn’t help but believe she was going to make it and see her daughter again.

On December 3, a delegation from the U.S. government was visiting the ETU. This happened to be the same day Korto finally received her negative Ebola test, clearing her for discharge. Korto left the patient ward giggling, laughing, and soaking in the cheers from the delegation and ETU staff, and she was finally reunited with Josephine that day.

Korto noticed late that evening that Josephine had diarrhea, as well as a cough and fever. The next morning, Korto was back at the ETU, and our whole team sighed with the saddest disappointment. Seeing mother and baby back in the patient ward was difficult, but our doctors, nurses, and psychosocial support staff encouraged Korto to keep breastfeeding, which provides the best source of nutrition for an infant.

For more than two weeks, Josephine’s condition fluctuated. She would become very sick one day, then a bit stronger the next day, and then very feverish the next. Because Josephine was so small, the only way to give her the additional fluids she needed was through an intravenous drip placed in a vein on her head. There were several days when we held our breath, hoping to see Josephine alive as we began each shift. Eventually she gained strength. Her eyes were no longer puffy and tired but became bright and attentive. She held her little head, now shaved for the IV, higher and higher each day.

Photo courtesy of International Medical Corps

Finally on December 22, our colleague from the U.S. Navy lab, brought in to expedite Ebola testing in the area, could not hide the excitement in his voice when he relayed the news to the team. Josephine had tested negative for Ebola. Many tears of joy flowed from all of our staff and about everyone else who heard the news. Korto, of course, started dancing and clapping, smiling big with her grin we all love. And for the first time in weeks, Josephine let a small smile peek through.

We have all seen so much devastation working on this outbreak in West Africa. In our ETU, we’ve lost several young patients, but bright moments like seeing Korto and Josephine together and well spur our team to continue the fight against Ebola alongside our partners and the people of Liberia.

To date, International Medical Corps’ Ebola Treatment Unit in Bong County, Liberia, has discharged 74 survivors, including Korto and Josephine. International Medical Corps is operating an additional ETU in Margibi County, Liberia, and has trained over 150 health care and other workers in Liberia to date, including senior management and experts from the Liberian Ministry of Public Works, Ministry of Health and Social Welfare, and the Ministry of Defense. In addition, International Medical Corps teams are also working to fight Ebola in Sierra Leone and Mali.

“Death is always difficult,” said Elizabeth Stevens, a nurse from Freetown, Sierra Leone.
At her new job, Stevens is forced to confront this stark reality every day, and in a way that she never has before.

“The first day, when I entered the [medical] ward, I was frightened,” said Stevens. “But now it’s getting better.”

It’s been just a week since a new Ebola treatment unit (ETU) opened on December 1 in the town of Lunsar in Sierra Leone’s Port Loko district—an area with one of the highest rates of Ebola in the country. On its first day of operation, four patients were admitted to the facility being run by International Medical Corps (IMC) with USAID support. USAID provided more than $5 million for the staffing and management of the 50-bed ETU.

According to the ETU’s medical director, some of the facility’s 150 staff members were nervous to start caring for Ebola patients in spite of all the training they received. But by day three, things started coming together.

“For the first two days, you could see people’s anxiety…more of the fear of it being real,” said IMC medical director Vanessa Wolfman. “But we have a great psychosocial team to talk to staff about their fears. Now we’re getting into a routine. Everyone’s much more comfortable and can rely on each other.”

This reliance and teamwork is evident even before the first patient is seen. On one end of the medical complex, there’s a small group of people around emergency room nurse Lisa Woods, helping her get into the protective suit, gloves, apron, boots, and goggles that will keep her safe while treating Ebola patients.

“You don’t have any touch with the patients,” said Woods, her voice slightly muffled from the mask covering half her face; giant red goggles cover the other half. “I think that’s the hardest part, not being able to connect with my patients in a human way. Like right now there’s a 14-year-old in there, and boy, that’s hard.”

On the other end of the treatment complex, groups of men and women are washing hundreds of articles of clothing, boots, goggles, and gloves by hand. Right next to them, several people are hooking up a washing machine that was recently delivered—just in time to speed up the laundering process before more patients arrive and the ETU gets busier.

“We are really sympathetic with the patients,” said Idrissa Kamara, a nurse at the ETU. “These people are our people. So we take great care of them because we don’t want to see them missing.”

Just then, the medical director announces that another ambulance is on its way with a confirmed Ebola patient. Idrissa and the other nurses walk out of the staff rest area, to suit up and take care of another one of their own.

A look into the hot zone: This is one of the few places where water and food could be passed from the safe zone to the patient areas. Orange fencing indicates the areas where staff must be wearing protective clothing. / Carol Han, USAID

An ambulance brings a patient to the newly opened Ebola treatment unit (ETU) in Sierra Leone’s Port Loko district, one of the areas hardest hit by the epidemic. / Carol Han, USAID

Lisa Woods is an emergency room nurse from San Francisco who came to Sierra Leone to work at the USAID-supported ETU. “To give to somebody, what greater gift is that?” said Woods. Photo credit: / Carol Han, USAID

Most of the 150 people working at the ETU are Sierra Leonean. “All of us are working in unity,” said nurse Elizabeth Stevens (far left). / Carol Han, USAID

Hundreds of articles of clothing, goggles, boots, and gloves are washed every single day by hand. A newly installed washing machine will speed up the laundering process. / Carol Han, USAID

Dream Team: A group of nurses suit up to go into the patient ward during their six-hour shift. It takes teamwork not only to work with patients, but to get dressed for duty. “It’s really been a great experience,” said Lisa Woods (right). / Carol Han, USAID

“These people are our people,” said Idrissa Kamara, a nurse at the ETU. “So we take great care of them because we don’t want to see them missing.” / Carol Han, USAID

ABOUT THE AUTHORS

The Ebola Disaster Assistance Response Team (DART) is overseeing the U.S. Ebola response efforts in West Africa. The DART includes staff from across the U.S. Government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

A woman in the Philippines receives a tetanus shot during a pre-natal visit. / HealthPRO

The 2010 World Health Report on Health Systems Financing and the unanimous endorsement of Universal Health Coverage (UHC) by the United Nations in 2012 have paved the way for rich and poor countries alike to take a closer, more critical look at how raise resources and improve access to health services, particularly for the poor. Asia is home to 3.9 billion people and accounts for a third of the global economy. Despite the region’s robust economic growth, almost two thirds of those in extreme poverty still live in Asia.

While there are many paths that a country can choose to get out of poverty, mobilizing domestic resources towards the health sector – in the form of Universal Health Coverage policies that seek to increase access to services especially for the poor – is a sound and sustainable investment that can lead to great economic returns. These reforms that empower the poor are critical because poor health and health shocks are leading causes of chronic poverty and impoverishment.

An Indonesian patient awaits further instructions during a check-up. / USAID

Ill health prevents the poor from climbing out of poverty and can impoverish the near poor. When a household member falls ill, this can mean diminished labor productivity. In addition, households often make catastrophic financial outlays paid for by selling their assets, reducing their consumption, dipping into their savings, or borrowing at high interest rates for seeking health care.

High rates of out-of-pocket spending, a highly regressive way of financing health systems, create financial barriers to accessing health care., This financing represents 36 percent and 61 percent of the total health spending in developing East Asia and Pacific and South Asia regions, respectively.

UHC reforms come in different shapes and sizes. Some common characteristics include improving revenue collection mechanisms so that they are fair and affordable;, helping people move away from paying for health services out of pocket and toward prepayment and risk pooling; improving value for money with strategic purchasing;, and targeting the poor through subsidies.

Many of these reforms across Asia have increased access and utilization of health care, provided financial protection, as well as improved health care outcomes.

Countries such as China and Bangladesh successfully piloted schemes. In Bangladesh, the pilot voucher program to improve maternal and child health successfully increased pre-and post-natal care and facility-based deliveries, while reducing out-of-pocket spending and the costs of these services, and decreasing neonatal mortality rates by a third to almost half in home-based interventions. Bangladesh has adopted UHC as a national policy goal and USAID is providing assistance to support implementation of their health financing strategy.

Vietnam and Indonesia have reached partial coverage of their populations by around two thirds, and have recently taken additional steps to expand their coverage.

Analysis of various UHC schemes in Vietnam (public voluntary health insurance, social insurance and the health care fund for the poor) showed that they had improved financial protection – significantly decreasing spending for the beneficiary insured and providing evidence of positive impacts on their nutrition indicators. And in January of this year, Indonesia set out on the path towards UHC with the goal of covering its entire population of 250 million people by 2019.

The dynamic economic environment in fast-growing Asia means that the role of donors like USAID and the development assistance architecture will need to evolve as well.

Individual countries and the region at large will need to grapple with growing migrant populations and the need for portable schemes that ensure access for migrant labor populations across porous borders. A large and growing informal sector, individuals not covered by the labor and social security provisions, will continue to test how countries communicate expanded coverage to remote and often marginalized communities. Equally as important will be the question of how to finance and address the changing mix of population health needs arising from demographic trends and the emergence of non-communicable diseases.

As many of the developing countries in Asia continue to grow, they will have sufficient resources to afford a basic package of health services for their entire population; however, governments tend to under-invest in their health sector relative to their economic potential.

As a result, oftentimes as countries grow wealthier, public health systems fall further behind.

In Asia and globally, growing domestic resources represent a critical window of opportunity where countries must have the vision and courage to strategically direct this increased wealth towards the health sector so that development dollars are crowded out.

ABOUT THE AUTHOR

Kristina Yarrow is a Senior Health Technical Specialist in the Asia Bureau, backstopping technical areas specific to health systems strengthening and research such as health financing, UHC, and implementation research.

Caroline Ly is a Health Economist in the Bureau for Global Health’s Office of Health Systems.

A mother plays with her child while waiting for services at Jose Maria Cabral y Baez Hospital in Santiago, Dominican Republic. Health workers and supervisors from this hospital participated in a workshop to improve the quality of services to eliminate mother-to-child transmission of HIV. / Wendy Tactuk, courtesy of CapacityPlus and IntraHealth International

This week we mark World AIDS Day. Appropriately, it occurs during the Sixteen Days of Activism Against Gender-Based Violence. Why so appropriate? Because we know that gender-based violence (GBV) prevention and response are critical to effectively treating and reducing the spread of HIV. Though not always self-evident, the connection is clear.

For me, the linkages were driven home during recent conversations I had with health experts in Ghana. While discussing our health programs, I casually asked how important attention to GBV was within efforts to treat and stem the spread of the HIV. As soon as I asked the question, the room’s atmosphere changed palpably. Everyone sat up and leaned in. People began speaking all at once, tripping over one another to respond. The passion was tangible and the analysis compelling. It was all the more persuasive because it is backed up by research.

In Ghana, the HIV rate is low and declining, though the rate is 15 – 20 times higher for key populations at risk of contracting HIV, which include female sex workers (FSWs) and men who have sex with men.

GBV is particularly common among female sex workers (FSWs), 24 – 37 percent of whom are HIV-positive. How do GBV and HIV rates correlate and relate, and how do we bear that in mind in our work to prevent and treat the infected?

Many of my conversations in Accra focused on how to help people change behavior to decrease the risk of transmitting the virus and to increase the likelihood of seeking testing and treatment. The experts discussed how much more difficult it is for a woman or a man to negotiate condom use with an abusive partner.

The victim is less likely to try to persuade the abuser to use protection. The perpetrator is less likely to listen. The practitioners also talked about how victims of gender-based violence have less self-esteem and a lowered sense of self-worth. As a result, victims of abuse don’t believe they have the “right” to receive health services. It is much harder to coax people who face GBV or who fear violence or abandonment to seek services, test for HIV, or to successfully access or adhere to treatment.

A 2010 study of FSWs in Karnataka state, south India, confirmed what the Ghanaians explained to me; fear of partner violence prevented women and girls from seeking health services and from asking their partners to use condoms. The study found that condom use was some 20 percent lower those who had been beaten or raped within the last year compared with those who had not faced such violence.

The experts I spoke with also mentioned how gender-based violence cements relationships in which one partner is clearly dominant; they discussed how that feeling of dominance can give the abusive partner a sense of invincibility, reducing his or her willingness to practice prevention.

If you don’t believe you are vulnerable to harm or disease, there is no need to protect yourself. A 2014 study in South Africa supported this contention. The study, which considered women and girls attending four health centers in Soweto, found that abusive relationships with high levels of male control were “associated with HIV seropositivity.” In relationships where men had a great deal of power or where violence was frequent, researchers found that females were less likely to request condom use and had about a 12 percent greater likelihood of being HIV-positive.

Sometimes, the statistics were actually pretty astonishing. A 2012 study in Moscow, Russia found that FSWs were more than 20 percent more likely to be HIV-positive or to carry a sexually transmitted infection (STI) if they experienced client violence. In addition, over forty percent of FSWs who were coerced into sex with the police were STI/HIV infected. Researchers concluded that reducing the risk of infection would require decreasing client, pimp and police abuse and coercive behavior.

A 2013 WHO systematic global review and analysis of studies across different HIV epidemic settings underscored the association between GBV and HIV, finding that intimate partner violence increases the risk for HIV infection among women and girls by more than 50 percent, and in some instances up to four-fold.

There are two bottom lines to the research and experiential data. First, reducing and responding to gender-based violence should be a key tool in efforts to prevent the spread of HIV. Second, additional research is needed to understand those violence-reducing interventions that best reinforce HIV prevention and treatment.

USAID has seen important dividends from integrating GBV prevention and response into HIV and AIDS programs in collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). In Tanzania, USAID has supported development of National Management Guidelines for Health Response and Prevention to GBV, which provide a framework to guide comprehensive management of GBV survivors.

The Guidelines have led to training of health care providers and roll-out of a GBV register at health facilities across the country. In Zambia, USAID with PEPFAR funding, is collaborating with the British Department for International Development (DFID) and six government ministries to strengthen the response to GBV; this includes doubling the number of one-stop centers in several provinces, reaching 5 million adults and children with preventive messages, assisting 47,000 survivors, and training 200 police and justice sector personnel through 2018.

All told, USAID has contributed significantly to important results under PEPFAR; in FY2013, 2.5 million people in 12 countries were reached by efforts to address GBV and coercion, and an additional 800 health facilities began offering GBV screening, assessment and/or referrals to service providers.

The connection between gender-based violence and HIV infection is unambiguous. The data combined with the experience and perspectives of field experts make it clear. As we renew our commitments this week both to combat the spread of AIDS and to prevent GBV, let’s recognize and ensure that programs address the intersection. It could make the difference between the success and failure of efforts around the world.

ABOUT THE AUTHOR

Carla Koppell is USAID’s Chief Strategy Officer. She was formerly the Agency’s Senior Coordinator for Gender Equality and Women’s Empowerment. You can follow her @CarlaKoppell

Liberia is in the midst of a building boom to help control the spread of Ebola. In support of the Liberian Government’s Ebola response strategy, the United States is in the process of constructing 15 Ebola treatment units (ETUs) in this hard-hit nation. Across the country, teams of workers are busy moving dirt, laying concrete, trucking in construction materials, and erecting large white tents.

The first ETU to be built and staffed by the U.S.—in the city of Tubmanburg—started receiving patients on November 18. Now, a second ETU supported by the United States is operational in the city of Kakata, about 45 miles northeast of Monrovia. Built by the organization Save the Children with support from USAID, the ETU is being run by International Medical Corps (IMC), which is also managing another ETU in Bong County, Liberia.

Members of USAID’s Ebola Disaster Assistance Response Team (DART) visited the site on November 22, joining a Liberian delegation that included the Assistant Minister of Health and county health officials. Below is an inside look at the USAID-supported ETU, including those areas that are currently off limits to cameras now that the facility is open to Ebola patients.

About an hour’s drive northeast of Monrovia, in the heart of Liberia’s rubber cultivation belt, the second Ebola treatment unit (ETU) in Liberia to be constructed and staffed with U.S. Government assistance is now receiving patients. / Justin Pendarvis, USAID/OFDA

The facility was built by Save the Children with USAID providing construction materials, gravel, cots for patients, generators to power the ETU, and other support. The red fencing separates public areas from Ebola “hot zones.” / Justin Pendarvis, USAID/OFDA

More than 160 people—mostly Liberian national staff—work at the ETU. For the past two weeks, IMC’s medical team received rigorous training on Ebola patient care, safety protocols, and ETU management. / Alisha McMichael, USAID/OFDA

The 88-bed ETU, which opened on November 22, has received a number of patients. Some were discharged after testing negative for Ebola. / Alisha McMichael, USAID/OFD

NO DETAIL OVERLOOKED: Inside the clinical care areas are electrical outlets where patients can play music or charge their cell phones to keep in touch with their loved ones. USAID provided generators to power the ETU. / IMC

ABOUT THE AUTHOR

The Ebola Disaster Assistance Response Team (DART) is overseeing the U.S. Ebola response efforts in West Africa. The DART includes staff from across the U.S. Government, including USAID’s Office of U.S. Foreign Disaster Assistance (OFDA), the U.S. Centers for Disease Control and Prevention (CDC), and the Departments of Defense and Health and Human Services.

As we commemorate World AIDS Day this year, let’s take a moment to remember how far we’ve come, and where we must go. There are currently 35 million people living with HIV worldwide, and 13.6 million of those people are receiving antiretroviral therapy. New HIV infections continue to decline each year, with 2.1 million in 2013, which was 38 percent lower than in 2001. However, over 4,000 people continue to die from AIDS each and every day.

In accordance with the immense toll that HIV and AIDS have taken on the world, the U.S. Government established the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 as the single largest commitment by any nation to combat a single disease. Since then, working closely with many partners, PEPFAR has supported lifesaving antiretroviral therapy for more than 6.7 million men, women and children. As a key implementing agency of PEPFAR, USAID has made significant contributions to this remarkable progress. But, together, we have more work to do to finish the job.

UNAIDS has identified the 90-90-90 targets by 2020. These milestones aim to have 90 percent of people living with HIV know their status, 90 percent of people who know their status receive treatment, and 90 percent of people on HIV treatment having a suppressed viral load so their immune system remains strong and they are no longer infectious. In order to achieve these goals and have a lasting response to this epidemic, we must examine what is required to sustain HIV treatment for decades to come.

India World AIDS Day 2008 / AFP/Narinder Nanu/Getty Images

The vision for the next phase of PEPFAR is partnering to deliver an AIDS-free generation with sustainable results.However, a sustainable response to this epidemic requires intensified action to address major ongoing challenges such as health care financing, health systems and new technologies for treatment and prevention. And there is a special need for increased attention to the human rights of key affected populations. These include sex workers, men who have sex with men, transgender persons and persons who inject drugs.

The high vulnerability of key populations to HIV is disturbing. Compared to the general population, sex workers are 14 times more likely to be infected with HIV; men who have sex with men are 19 times more likely to be infected; and the limited data we have on transgender women suggest that they are 49 times more likely to be infected with HIV. Equally unsettling are the global estimates that the number of people living with HIV who inject drugs range from over 1 million to slightly less than 4 million people.

Barriers to essential services prohibit these figures from coming down. Stigma and discrimination, violence, criminalization, bad or ineffective policies, and opposition to civil society engagement present real challenges. One of the most egregious barriers is the lack of acknowledgement by governments and other leaders that key populations even exist and/or are underserved. As I have observed over the years, the most insidious form of oppression is to ignore a people.

Fortunately, that pessimistic view is tempered by the knowledge that these barriers can be overcome. We know from experience that effective programs can reach key populations with high quality, effective services, and that key populations infected with HIV can be linked to the care and treatment services that they desperately need. On Thursday, Dec. 4, we will highlight the importance of key populations in the HIV epidemic at the D.C. launch of USAID’s PEPFAR-funded LINKAGES project.

The U.S. Government’s official theme for World AIDS 2014 is Focus, Partner, Achieve: An AIDS-free Generation. This theme captures the core elements of what is needed to reach this goal, which is outlined in the PEPFAR Blueprint. We must deliver the right thing, in the right place and at the right time. This means focusing on the highest impact interventions, bringing them to scale in key geographic areas and among the most vulnerable populations, including men who have sex with men, sex workers, injecting drug users, and transgender persons.

On this World AIDS Day, nearly 35 years into the epidemic, I am extremely proud of our collective progress. But, while an AIDS-free generation is within our reach, we must not stop until it becomes our reality.